Client Details

First name

Last name

Email

Phone

What type of service are you looking for?

Psychiatric Evaluation

Medication Management

Not sure yet

Other

Are you specifically seeking a particular medication?

No

Yes

Prefer to discuss with provider

What are you hoping to get out of working together? (Please do not include detailed medical or personal health information.)

Have you previously worked with a mental health provider?

Yes

No

Are you currently experiencing an urgent situation that requires immediate care?

No

Yes

I understand this is an outpatient practice and does not provide emergency services

I understand that appointments are reviewed prior to confirmation

I understand that treatment, including medication, is based on clinical evaluation and is not guaranteed